Optimizing Chest Pain Diagnoses in the ED

An estimated 8 million people present to EDs in the United States with chest pain each year, 15% to 25% of whom receive a diagnosis of acute coronary syndrome (ACS). Of this group, between 2% and 5% are discharged home without an ACS diagnosis but receive one within 30 days. Due to a fear of missing this subset of patients, many people presenting to the ED with chest pain are unnecessarily admitted to the hospital for observation and further investi­gation. These cases can clog EDs, increase the likelihood of unneeded testing, and increase healthcare costs (see also, A New Look at Leaving Without Being Seen in EDs). Algorithm to Manage Chest Pain Put to the Test My colleagues and I in the department of emergency medi­cine collaborated with the cardiology and nuclear medicine departments at our hospital. We developed an algorithm designed to streamline approaches for managing patients with potential cardiac chest pain. Our algorithm was evaluated in a study published in the April 2012 Annals of Emergency Medicine. With the algorithm, patients who presented to the ED with chest pain underwent a full history and physical examina­tion, along with EKG and biomarker testing. Patients with high-risk clinical features (eg, worsening angina or an EKG suspicious for ischemia or positive troponins) were referred to the cardiology department immediately. The remainder of patients had tests repeated at both 2 and 6 hours. Those who developed new pain, had ongoing pain, had changes on EKG, or had subsequent positive troponin levels were referred to the cardiology department as well. If patients did not have high-risk clinical features, had a normal EKG,...